CMS-10398. GenIC # Monitoring Protocol Workbook

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

7b - Monitoring Protocol Workbook (2020 version 3).xlsx

GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

Overview

PRA Disclosure Statement
SMI-SED planned metrics
SMI-SED definitions
SMI-SED planned subpopulations
SMI-SED reporting schedule

Sheet 1: PRA Disclosure Statement
PRA Disclosure Statement This information is being collected to assist the Centers for Medicare & Medicaid Services in program monitoring of Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations. This mandatory information collection (42 CFR § 431.428) will be used to support more efficient, timely and accurate review of states’ monitoring report submissions of Medicaid Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations, and also support consistency in monitoring and evaluation, increase in reporting accuracy, and reduction in timeframes required for monitoring and evaluation. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
End of worksheet
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #59). The time required to complete this information collection is estimated to average 29 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Sheet 2: SMI-SED planned metrics

Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - Planned metrics (Version 2.0, revised)


















State [Enter State Name]

















Demonstration Name [Enter Demonstration Name]




































Serious Mental Illness/Serious Emotional Disturbance (SMI/SED) Planned Metrics





















Standard information on CMS-provided metrics






Baseline, annual goals, and demonstration target Alignment with CMS-provided technical specifications manual Phased-in metrics reporting
# Metric name Metric description Milestone or reporting topic Metric type Reporting category Data source Measurement period Reporting frequency Reporting priority State will report (Y/N) Baseline Reporting Period (MM/DD/YYYY--MM/DD/YYYY) Annual goal Overall demonstration target Attest that planned reporting matches the CMS-provided technical specifications manual (Y/N) Explanation of any deviations from the CMS-provided technical specifications manual (different data source, definition, codes, target population, etc.) State plans to phase in reporting (Y/N) Report in which metric will be phased in (Format SMI/SED DYQ; Ex. DY1Q3) Explanation of any plans to phase in reporting over time
EXAMPLE:
24
(Do not delete or edit this row)		 EXAMPLE:
Screening for Depression and Follow-Up Plan: Age 18 and Older (CDF-AD)		 EXAMPLE:
Percentage of beneficiaries age 18 and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool, AND if positive, a follow-up plan is documented on the date of the positive screen.		 EXAMPLE:
Milestone 4		 EXAMPLE:
Established quality measure		 EXAMPLE:
Annual metrics that are an established quality measure		 EXAMPLE:
Claims
Medical records		 EXAMPLE:
Year		 EXAMPLE:
Annually		 EXAMPLE:
Recommended		 EXAMPLE:
Y		 EXAMPLE:
01/01/2020-12/31/2020		 EXAMPLE:
Increase		 EXAMPLE:
Increase		 EXAMPLE:
N		 EXAMPLE:
The Department will use state-defined procedure codes (list specific codes) to calculate this metric.		 EXAMPLE:
Y		 EXAMPLE:
DY3Q1		 EXAMPLE:
We are transitioning to a new tool to screen for depression in adults (i.e., we are transitioning from the Duke Anxiety-Depression Scale (DADS) to the Patient Health Questionnaire [PHQ-2 & PHQ-9]). We anticipate that this transition will be complete across sites by mid to late 2021 (DY2).
1 SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential Treatment Settings (SUB-2) Two rates will be reported for this measure:
1. SUB-2: Patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay.
2. SUB-2a: Patients who received the brief intervention during the hospital stay.		 Milestone 1 Established quality measure Annual metrics that are an established quality measure Medical record review or claims Year Annually Recommended









2 Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH) Percentage of children and adolescents ages 1 to 17 who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment. Milestone 1 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









3 All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From Integrated Physical and Behavioral Health Care (PMH-20) Number of all-cause ED visits per 1,000 beneficiary months among adult Medicaid beneficiaries age 18 and older who meet the eligibility criteria of beneficiaries with SMI. Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









4 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility (IPF) The rate of unplanned, 30-day, readmission for demonstration beneficiaries with a primary discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease. The measurement period used to identify cases in the measure population is 12 months from January 1 through December 31. Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









5 Medication Reconciliation Upon Admission Percentage of patients for whom a designated prior to admission (PTA) medication list was generated by referencing one or more external sources of PTA medications and for which all PTA medications have a documented reconciliation action by the end of Day 2 of the hospitalization. Milestone 2 Established quality measure Annual metrics that are an established quality measure Electronic/paper medical records Year Annually Recommended









6 Medication Continuation Following Inpatient Psychiatric Discharge This measure assesses whether psychiatric patients admitted to an inpatient psychiatric facility (IPF) for major depressive disorder (MDD), schizophrenia, or bipolar disorder filled a prescription for evidence-based medication within 2 days prior to discharge and 30 days post-discharge. Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









7 Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH) Percentage of discharges for children ages 6 to 17 who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:
• Percentage of discharges for which the child received follow-up within 30 days after discharge
• Percentage of discharges for which the child received follow-up within 7 days after discharge		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









8 Follow-up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD) Percentage of discharges for beneficiaries age 18 years and older who were hospitalized for treatment of selected mental illness diagnoses or intentional self-harm and who had a follow-up visit with a mental health practitioner. Two rates are reported:
• Percentage of discharges for which the beneficiary received follow-up within 30 days after discharge
• Percentage of discharges for which the beneficiary received follow-up within 7 days after discharge		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









9 Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse (FUA-AD) Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a primary diagnosis of alcohol or other drug (AOD) abuse dependence who had a follow-up visit for AOD abuse or dependence. Two rates are reported:
• Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 30 days of the ED visit
• Percentage of ED visits for AOD abuse or dependence for which the beneficiary received follow-up within 7 days of the ED visit		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









10 Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD) Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a primary diagnosis of mental illness or intentional self-harm and who had a follow-up visit for mental illness. Two rates are reported:
• Percentage of ED visits for mental illness for which the beneficiary received follow-up within 30 days of the ED visit
• Percentage of ED visits for mental illness for which the beneficiary received follow-up within 7 days of the ED visit		 Milestone 2 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









11 Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count) Number of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED within 7 and 30 days of discharge from an inpatient facility or residential stay for mental health. Milestone 2 CMS-constructed Other annual metrics State data on cause of death Year Annually Recommended









12 Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate) Rate of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED within 7 and 30 days of discharge from an inpatient facility or residential stay for mental health. Milestone 2 CMS-constructed Other annual metrics State data on cause of death Year Annually Recommended









13 Mental Health Services Utilization - Inpatient Number of beneficiaries in the demonstration population who use inpatient services related to mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









14 Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization Number of beneficiaries in the demonstration population who used intensive outpatient and/or partial hospitalization services related to mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









15 Mental Health Services Utilization - Outpatient Number of beneficiaries in the demonstration population who used outpatient services related to mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









16 Mental Health Services Utilization - ED Number of beneficiaries in the demonstration population who use emergency department services for mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









17 Mental Health Services Utilization - Telehealth Number of beneficiaries in the demonstration population who used telehealth services related to mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









18 Mental Health Services Utilization - Any Services Number of beneficiaries in the demonstration population who used any services related to mental health during the measurement period. Milestone 3 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









19a Average Length of Stay in IMDs Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient or residential stay in an IMD. Three rates are reported:
• ALOS for all IMDs and populations
• ALOS among short-term stays (less than or equal to 60 days)
• ALOS among long-term stays (greater than 60 days)		 Milestone 3 CMS-constructed Other annual metrics Claims
State-specific IMD database		 Year Annually Required









19b Average Length of Stay in IMDs (IMDs receiving FFP only) Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient or residential stay in an IMD receiving federal financial participation (FFP). Three rates are reported:
• ALOS for all IMDs and populations
• ALOS among short-term stays (less than or equal to 60 days)
• ALOS among long-term stays (greater than 60 days)		 Milestone 3 CMS-constructed Other annual metrics Claims
State-specific IMD database		 Year Annually Required









20 Beneficiaries With SMI/SED Treated in an IMD for Mental Health Number of beneficiaries in the demonstration population who have a claim for inpatient or residential treatment for mental health in an IMD during the reporting year. Milestone 3 CMS-constructed Other annual metrics Claims Year Annually Required









21 Count of Beneficiaries With SMI/SED (monthly) Number of beneficiaries in the demonstration population during the measurement period and/or in the 11 months before the measurement period. Milestone 4 CMS-constructed Other monthly and quarterly metrics Claims Month Quarterly Required









22 Count of Beneficiaries With SMI/SED (annually) Number of beneficiaries in the demonstration population during the measurement period and/or in the 12 months before the measurement period. Milestone 4 CMS-constructed Other annual metrics Claims Year Annually Required









23 Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (HPCMI-AD) Percentage of beneficiaries ages 18 to 75 with a serious mental illness and diabetes (type 1 and type 2) whose most recent Hemoglobin A1c (HbA1c) level during the measurement year is >9.0%. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Medical records		 Year Annually Required









24 Screening for Depression and Follow-Up Plan: Age 18 and Older (CDF-AD) Percentage of beneficiaries age 18 and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool, AND if positive, a follow-up plan is documented on the date of the positive screen. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Medical records		 Year Annually Recommended









25 Screening for Depression and Follow-Up Plan: Ages 12–17 (CDF-CH) Percentage of beneficiaries ages 12 to 17 screened for depression on the date of the encounter using an age appropriate standardized depression screening tool, AND if positive, a follow-up plan is documented on the date of the positive screen. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims
Electronic medical records		 Year Annually Recommended









26 Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI The percentage of Medicaid beneficiaries age 18 years or older with SMI who had an ambulatory or preventive care visit during the measurement period. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









27 Tobacco Use Screening and Follow-up for People with SMI or Alcohol or Other Drug Dependence The percentage of patients 18 years and older with a serious mental illness or alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user. Two rates are reported:
• Percentage of adults with SMI who received a screening for tobacco use and follow-up for those identified as a current tobacco user
• Percentage of adults with AOD who received a screening for tobacco use and follow-up for those identified as a current tobacco user		 Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Recommended









28 Alcohol Screening and Follow-up for People with SMI The percentage of patients 18 years and older with a serious mental illness, who were screened for unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy alcohol user. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Recommended









29 Metabolic Monitoring for Children and Adolescents on Antipsychotics The percentage of children and adolescents ages 1 to 17 who had two or more antipsychotic prescriptions and had metabolic testing. Three rates are reported:
•Percentage of children and adolescents on antipsychotics who received blood glucose testing
•Percentage of children and adolescents on antipsychotics who received cholesterol testing
•Percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol testing		 Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









30 Follow-Up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic Medication Percentage of Medicaid beneficiaries age 18 years and older with new antipsychotic prescriptions who have completed a follow-up visit with a provider with prescribing authority within four weeks (28 days) of prescription of an antipsychotic medication. Milestone 4 Established quality measure Annual metrics that are an established quality measure Claims Year Annually Required









32 Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not Inpatient or Residential The sum of all Medicaid spending for mental health services not in inpatient or residential settings during the measurement period. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









33 Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient or Residential The sum of all Medicaid costs for mental health services in inpatient or residential settings during the measurement period. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









34 Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not Inpatient or Residential Per capita costs for non-inpatient, non-residential services for mental health, among beneficiaries in the demonstration population during the measurement period. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









35 Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient or Residential Per capita costs for inpatient or residential services for mental health among beneficiaries in the demonstration population during the measurement period. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









36 Grievances Related to Services for SMI/SED Number of grievances filed during the measurement period that are related to services for SMI/SED. Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required









37 Appeals Related to Services for SMI/SED Number of appeals filed during the measurement period that are related to services for SMI/SED. Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required









38 Critical Incidents Related to Services for SMI/SED Number of critical incidents filed during the measurement period that are related to services for SMI/SED. Other SMI/SED metrics CMS-constructed Grievances and appeals Administrative records Quarter Quarterly Required









39 Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With SMI/SED Total Medicaid costs for beneficiaries in the demonstration population who had claims for inpatient or residential treatment for mental health in an IMD during the reporting year. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









40 Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With SMI/SED Per capita Medicaid costs for beneficiaries in the demonstration population who had claims for inpatient or residential treatment for mental health in an IMD during the reporting year. Other SMI/SED metrics CMS-constructed Other annual metrics Claims Year Annually Required









Q1 [Insert selected metric(s) for health IT question 1]
Health IT State-specific



Required









Q2 [Insert selected metric(s) for health IT question 2]
Health IT State-specific



Required









Q3 [Insert selected metric(s) for health IT question 3]
Health IT State-specific



Required









State-specific metrics


















Add rows for any additional state-specific metrics






































Sheet 3: SMI-SED definitions

Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - SMI/SED Definitions (Version 2.0, revised)

State [Enter State Name]

Demonstration Name [Enter Demonstration Name]



Serious Mental Illness/Serious Emotional Disturbance (SMI/SED) Definitions

Narrative description of the SMI/SED demonstration population
EXAMPLEa
Adults age 18 or older with serious mental illness or children under the age of 18 with a serious emotional disturbance living within the state.
. Serious Mental Illness (SMI) Serious Emotional Disturbance (SED)
Narrative description of how the state defines the population for purposes of monitoring (including age range, diagnosis groups, and associated service use requirements) EXAMPLEa
*At least one acute inpatient claim/encounter with any diagnosis of schizophrenia, bipolar I disorder, or major depression, OR
*At least two visits in an outpatient, intensive outpatient (IOP), partial hospitalization (PH), emergency department (ED), or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia, OR
*At least two visits in an outpatient, IOP, PH, ED, or nonacute inpatient setting on different dates of service with a diagnosis of bipolar I disorder. 		See SMI example for format and required information
Codes used to identify populationb

States may use ICD-10 diagnosis codes or state-specific treatment, diagnosis, or other types of codes to identify the population. When applicable, states should supplement ICD-10 codes with state-specific codes.		 EXAMPLEa
*Schizophrenia: F20.0-F20.5, F20.81, F20.89
*Major depression: F32.0 - F32.4, F33.0 - F33.3
*Bipolar I disorder: F30.10-F30.13, F30.2 - F30.9		 See SMI example for format and required information
Procedure (e.g., CPT, HCPCS) or revenue codes used to identify/define service requirementsb

If the state is not using procedure or revenue codes, the state should include the data source(s) (e.g., state-specific codes) used to identify/define service requirements.		 EXAMPLEa
*Outpatient: 98960-98962, 99211-99215, G0155, G0176, G0177, G0409, 0510, 0513, 0515-0517		 See SMI example for format and required information
aThe examples are based on a definition of SMI from the National Committee for Quality Assurance (NCQA). The examples provided are intended to be illustrative only. The example codes provided are not comprehensive.
bStates may choose to include codes as separate tabs in this workbook.

End of worksheet

  

Sheet 4: SMI-SED planned subpopulations

Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - Planned subpopulations (Version 2.0, revised)








State [Enter State Name]







Demonstration Name [Enter Demonstration Name]
















Serious Mental Illness/Serious Emotional Disturbance (SMI/SED) Planned Subpopulations








Planned subpopulation reporting Alignment with CMS-provided technical specifications manual






Subpopulations Relevant metrics
Subpopulation category Subpopulations Reporting priority Relevant metrics Subpopulation type State will report (Y/N) Attest that planned subpopulation reporting within each category matches the description in the CMS-provided technical specifications manual (Y/N) If the planned reporting of subpopulations does not match (i.e., column G = “N”), list the subpopulations state plans to report (Format: comma separated) Attest that metrics reporting for subpopulation category matches CMS-provided technical specifications manual (Y/N) If the planned reporting of relevant metrics does not match (i.e., column I = “N”), list the metrics for which state plans to report for each subpopulation category (Format: metric number, comma separated)
EXAMPLE:
Age group
(Do not delete or edit this row)		 EXAMPLE:
Children ( Age<16), Transition-age youth (Age 16-24), Adults (Age 25–64), Older adults (Age 65+)		 EXAMPLE:
Required		 EXAMPLE:
Metrics #11, 12, #13, 14, 15, 16, 17, 18, 21, 22		 EXAMPLE:
CMS-provided		 EXAMPLE:
Y		 EXAMPLE:
N		 EXAMPLE:
Children/Young adults (ages 12-21), Adults (ages 21-65)		 EXAMPLE:
Y		 EXAMPLE:
Standardized definition of SMI Individuals who meet the standardized definition of SMI Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




State-specific definition of SMI Individuals who meet the state-specific definition of SMI Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 State-specific




Age group Children ( Age<16), Transition-age youth (Age 16-24), Adults (Age 25–64), Older adults (Age 65+) Required Metrics #11, 12, 13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Dual–eligible status Dual-eligible (Medicare-Medicaid eligible), Medicaid only Required Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Disability Eligible for Medicaid on the basis of disability, Not eligible for Medicaid on the basis of disability Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Criminal justice status Criminally involved, Not criminally involved Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Co-occurring SUD Individuals with co-occurring SUD Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




Co-occurring physical health conditions Individuals with co-occurring physical health conditions Recommended Metrics #13, 14, 15, 16, 17, 18, 21, 22 CMS-provided




[Insert row(s) for any state-specific subpopulation(s)]


















End of worksheet








Sheet 5: SMI-SED reporting schedule

Medicaid Section 1115 SMI/SED Demonstrations Monitoring Protocol (Part A) - SMI/SED Reporting schedule (Version 2.0, revised)























State [Enter State Name]

























Demonstration Name [Enter Demonstration Name]




















































Serious Mental Illness/Serious Emotional Disturbance (SMI/SED) Reporting Schedule


























Instructions:























(1) In the reporting periods input table (Table 1), use the prompt in column A to enter the requested information in the corresponding row of column B. All report names and reporting periods should use the format DY#Q# or CY# and all dates should use the format MM/DD/YYYY with no spaces in the cell. The information entered in these cells will auto-populate the SMI/SED demonstration reporting schedule in Table 2. All cells in the input table must be completed in entirety for the standard reporting schedule to be accurately auto-populated.






















(2) Review the state's reporting schedule in the SMI/SED demonstration reporting schedule table (Table 2). For each of the reporting categories listed in column E, select Y or N in column G, "Deviations from standard reporting schedule (Y/N)" to indicate whether the state plans to report according to the standard reporting schedule. If a state's planned reporting does not match the standard reporting schedule for any quarter and/or reporting category (i.e. column G= “N”), the state should describe these deviations in column H, "Explanation for deviations (if column G="Y")" and use column I, “Proposed deviations from standard reporting schedule,” to indicate the SMI/SED measurement periods with which it wishes to overwrite the standard schedule (column F). All other columns are locked for editing and should not be altered by the state.















































Table 1. Reporting Periods Input Table























. Demonstration reporting periods/dates

























Dates of first SMI/SED reporting quarter:


























Reporting period
(Format SMI/SED DYQ; Ex. DY1Q1)


























Start date (MM/DD/YYYY)a


























End date (MM/DD/YYYY)

























Broader section 1115 demonstration reporting period corresponding with the first SMI/SED reporting quarter, if applicable. If there is no boarder demonstration, fill in the first SMI/SED reporting period.
(Format DYQ; Ex. DY3Q1)


























First SMI/SED report due date (per STCs)
(MM/DD/YYYY)


























First SMI/SED report in which the state plans to report annual metrics that are established quality measures (EQMs):


























Baseline period for EQMs
(Format CY; Ex. CY2019)


























SMI/SED DY and Q associated with report
(Format SMI/SED DYQ; Ex. DY1Q1)


























Start date (MM/DD/YYYY)


























End date (MM/DD/YYYY)


























Dates of last SMI/SED reporting quarter:


























Start date (MM/DD/YYYY)


























End date (MM/DD/YYYY)













































































































Table 2. SMI/SED Demonstration Reporting Schedule























Dates of SMI/SED reporting quarter
(MM/DD/YYYY - MM/DD/YYYY)		 Report due
(per STCs)
(MM/DD/YYYY)		 Broader section 1115 reporting period, if applicable; else SMI/SED reporting period
(Format DYQ; Ex. DY1Q3)		 Reporting category For each reporting category, measurement period for which information is captured in monitoring report per standard reporting schedule (Format DYQ; Ex. DY1Q3)b Deviation from standard reporting schedule
(Y/N)		 Explanation for deviations (if column G="Y") Proposed deviations from standard reporting schedule (Format DYQ; Ex. DY1Q3)


















Start date End date
SMI/SED






















Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics





















Annual availability assessment






















Annual metrics that are established quality measures





















Other annual metrics

























Narrative information





















Grievances and appeals





















Other monthly and quarterly metrics





















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics


























Narrative information






















Grievances and appeals






















Other monthly and quarterly metrics






















Annual availability assessment






















Annual metrics that are established quality measures






















Other annual metrics






















Add rows for all additional demonstration reporting quarters






















































Notes:


























a SMI/SED demonstration start date: For monitoring purposes, CMS defines the start date of the demonstration as the effective date listed in the state’s STCs at time of SMI/SED demonstration approval. For example, if the state’s STCs at the time of SMI/SED demonstration approval note that the demonstration is effective January 1, 2020 – December 31, 2025, the state should consider January 1, 2020 to be the start date of the demonstration. Note that that the effective date is considered to be the first day the state may begin its SMI/SED demonstration. In many cases, the effective date is distinct from the approval date of a demonstration; that is, in certain cases, CMS may approve a section 1115 demonstration with an effective date that is in the future. For example, CMS may approve an extension request on 12/15/2020, with an effective date of 1/1/2021 for the new demonstration period. In many cases, the effective date also differs from the date a state begins implementing its demonstration.






















b The auto-populated reporting schedule in Table 2 outlines the data the state is expected to reported for each SMI/SED demonstration year and quarter. However, the state is not expected to begin reporting any metrics data until after protocol approval. The state should see Section B of the Monitoring Report Instructions for more information on retrospective reporting of data following protocol approval.

AA# refers to the Annual Assessment of the Availability of Mental Health Services (“Annual Availability Assessment”) and the SMI/SED DY in which the Annual Availability Assessment will be submitted (for example, “AA1” refers to the Annual Availability Assessment that will be submitted with the state’s annual monitoring report for SMI/SED DY1). Data in each Annual Availability Assessment should be reported as of the month and day indicated in the state’s approved monitoring protocol. If the state cannot submit its Annual Availability Assessments when it submits its annual monitoring reports, it should propose and describe a reporting deviation in Columns G and H.






















End of worksheet




























































































































































































































File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00
© 2024 OMB.report | Privacy Policy